Epidurals and Breastfeeding

As Leaders, we believe that "alert and active participation by the mother in childbirth is a help in getting breastfeeding off to a good start." While this concept is evident in natural birth, many women today, including some of those involved in the Groups we lead, are opting to have epidural anesthesia during labor. According to the Maternity Center Association (MCA), 80 percent of women surveyed in the US used some type of pharmacological pain relief, with 63 percent of mothers choosing epidurals. In this survey, 59 percent of vaginal births took place with the use of epidural pain relief. The MCA report concludes, however, "Given the widespread use of epidurals and their popularity with mothers...a large percentage [of women]...appeared uninformed about potential side effects of epidurals" (Declerq et al. 2002). While it is well known that epidurals provide a high level of pain relief, what women may not know is that one of the many side effects of epidurals is the possible interference with breastfeeding initiation and duration.

The research studying the relationship between breastfeeding and epidurals has yielded conflicting results. A recent Canadian study (Chang and Heaman 2005) concluded that epidural use did not predict ineffective breastfeeding, problems with the newborn's neurobehavioral functioning, or weaning prior to four weeks. This study did find, however, that infants who were nursing well at eight to 12 hours old achieved a better score on the neurobehavioral exam, indicating that neurobehavioral testing may be able to detect infants prone to breastfeeding problems whether the mother had an epidural or not. Halpern and colleagues (1999) also found no connection between breastfeeding and epidural use. Of the 171 women who completed this study, 59 percent used an epidural for pain relief in labor. More than 70 percent were still exclusively nursing at the six-week postpartum interview, with an additional 20 percent partially breastfeeding They described their setting as "strongly supportive" of breastfeeding, which may account for the high percentages of women breastfeeding despite obstacles such as those that may be created with epidural use.

Other researchers have found results on the other end of the spectrum. Baumgarder et al. (2003) observed that 69.6 percent of babies exposed to epidural anesthesia had two successful nursing episodes in 24 hours, as opposed to 81 percent of babies not exposed to epidurals. This relationship remained even after controlling for demographic factors such as age, race, and number of previous births. In addition, these researchers found that babies whose mothers used epidural pain relief in labor were more likely to receive supplementary bottles before hospital discharge. In a randomized controlled trial of first-time, Australian mothers, researchers found that "breastfeeding duration was significantly longer in women who did not receive any pharmacological analgesia compared with women receiving narcotic or epidural analgesia...[and was] shortest in the women who received epidural analgesia in labor" (Henderson et al. 2003). The study calculated a 1.4 times greater risk for weaning prior to six months if the mother used an epidural for pain relief in labor. A retrospective study (a study looking back on events that have already occurred) published in the International Journal of Obstetrical Anesthesia found "67 percent of the mothers who had laboured with epidural analgesia and 29 percent of the mothers who laboured without epidural analgesia reported partial breastfeeding or formula feeding" at 12 weeks (Volmanen 2004). Interestingly, epidural use was also associated with perceived insufficient milk in this study, which has been found to predict early weaning.

In a study of 56 mother-baby pairs, Radzyminski (2003) found no significant difference between newborns born to medicated and unmedicated mothers. Babies were observed breastfeeding at birth and again at 24 hours, and neurobehavioral function in the newborn was tested at two and 24 hours. The author speculates that the ultra low dose epidural protocol in the study may be the reason that no statistical differences were noted. In a follow-up study, the same author (Radzyminski 2005) found that newborns who scored lower on the neurobehavioral test also scored lower on the breastfeeding measurement and gained less weight. Epidural use in this sample predicted lower scores on the neurobehavioral assessment, indicating possible central nervous system impairment. The author concludes that "slight differences in central nervous system functioning was sufficient to affect breastfeeding in the first day of life" in the sample of women studied. These results concur with the work of Swedish researchers who found labor medications "interfere with the newborn's spontaneous breast-seeking and breastfeeding behaviors" (Ransjö-Arvidson et al. 2001).

With such diverse findings, it is hard to form conclusions about epidural use and breastfeeding. An important consideration to keep in mind is that these results are based on how the individual studies were conducted in the first place. If the studies were flawed, the findings may be irrelevant. Are medicated babies being compared to less medicated babies or is a control group of unmedicated babies included? Are first-time mothers being compared to mothers who have already breastfed another baby? Are mothers assigned to the "no epidural" group of a study actually getting an epidural at some point during labor? One researcher puts the inconclusive results into perspective, writing:

This is not surprising considering the variety of drugs available for epidural anesthesia that can be given in multiple combinations, dosages, and methods of administration....supplementation and time of initiation of feeding were not controlled for in the study design; measurements of drug accumulations have not been reported; there has been a lack of control subjects; and the measurement tools used to evaluate breastfeeding have been in the early stages of development (Radzyminski 2003).

Using different measurement tools (for infant developmental function and breastfeeding behavior) in different studies, as well as not including a definition of breastfeeding, makes the results almost impossible to compare.

Even though there is not a firm link between epidural use and breastfeeding challenges, we do know that many epidural side effects can hinder breastfeeding success (Buckley 2005; Riordan and Riordan 2000; Riordan 1999; Walker 1997). It is important to keep these side effects in mind so that they can be offset when helping new mothers. When the decision is made to use an epidural during labor, a laboring mother is given a large amount of intravenous fluid, and this fluid continues to be infused throughout her labor and birth. While this is done to expand the blood volume and prevent a possible drop in the mother's blood pressure (Riordan and Riordan 2000), it can lead to overhydration. Breastfeeding problems related to receiving too much fluid include severely engorged breasts, making latch-on difficult. It is also possible for this excess fluid to show up in the baby's system and be quickly eliminated from the body, resulting in an exaggerated weight loss for the baby in the immediate postpartum period. Many health care providers feel that a loss of more than 10 percent of birth weight is cause for supplementation.

Epidural use necessitates several additional interventions: continuous fetal monitoring, blood pressure monitoring, and often restriction of movement because the laboring woman must remain in bed. Sometimes, after placement of the epidural, a woman's labor slows down. This can cause a domino effect, necessitating one intervention after another. If labor slows down, the health care provider may recommend that labor be augmented with synthetic oxytocin. When the mother is fully dilated, she may not have the urge to push, a common condition for women with epidurals. In such cases, forceps or vacuum extraction may be used to deliver the baby. These types of delivery may create a number of other problems, including requiring an episiotomy to enlarge the vaginal outlet for the instruments, thus making the mother's healing time longer than for a spontaneous vaginal birth. There is also the possibility of muscle and nerve damage to the baby (Kroeger and Smith 2004). If the pushing phase of labor is taking too long or the fetal heart rate begins to slow, the obstetrician may opt for a cesarean birth.

Another disturbing side effect of epidural anesthesia is maternal fever during labor. Buckley (2005) writes that "fever...is five times more likely overall for women using an epidural." A meta-analysis (a compilation of many studies on the same subject to find trends in and increase reliability of results) in the American Journal of Obstetrics and Gynecology concludes, "An increase in fever with epidural has been documented in both randomized controlled trials and observational studies" and is consistent when confounding factors (extraneous variables that have the potential to change the outcome of a study, such as race, age, and socioeconomic status) are accounted for (Lieberman and O'Donoghue 2002). In one study they cite, "90 percent of women with an elevated temperature had received epidural" (Lieberman et al. 1999) and women with higher than normal temperatures had three times more cesarean births and assisted deliveries. Because it is not possible to differentiate between a fever as a sign of infection or as a result of medication, mothers presenting with elevated temperature in labor are often treated with prophylactic antibiotics. Maternal fever can cause the baby's heart rate to go up, indicating possible fetal distress (Riordan and Riordan 2000). After birth, the baby may be separated from the mother so that doctors can rule out any infection and may be subjected to invasive procedures such as blood draws and IV antibiotics.

The side effects catalogued above are common when epidurals have been administered, and all of them can interfere with breastfeeding. Where does that leave an LLL Leader? We can teach pregnant women that skin-to-skin contact with their baby immediately after birth is the natural progression for a baby from the womb to the outside world. We can encourage them to practice this to not only get breastfeeding off to a good start, but to make the transition to "the real world" easier for the baby. After the mother is home from the hospital, Leaders can suggest co-bathing, or simply letting the baby lay against mother's naked chest as often as possible.

Nurses and lactation consultants have reported that babies exposed to epidurals tend to be sleepy and have difficulty in coordinating their sucking-swallowing-breathing, a necessary step to effective breastfeeding (Walker 1997; Riordan and Riordan 2000). We can help mothers by reviewing proper positioning and latch-on. If the baby is not latching on well, the mother may need to supplement with expressed colostrum (or later, with mature milk) to keep the baby well-hydrated. This will help to ensure that the baby has enough energy to nurse at the breast, thus protecting the mother's milk supply. We can review different ways to supplement in order to avoid using a bottle, such as using a nursing supplementer or spoon feeding. Feeding expressed milk will also help with weight gain, a concern in babies who are not nursing well at the breast and something that can happen even without an epidural. We can share with the mother various ways to rouse a sleepy baby and show her how to assess whether her baby is nursing well or not. Sometimes the baby just needs time and practice to learn how to nurse. Being conscious of the problems that can appear when mothers receive medications during labor prepares us as Leaders to be proactive if her baby needs a little help getting started nursing.

We can continue to encourage full participation in childbirth as an aid in initiating breastfeeding without compromising our relationships with the mothers who come to Series Meetings. By gently reminding women that they are capable of normal birth, just as they are capable of nursing their baby, we can create confidence and empowerment. We can encourage mothers to ask questions and get the answers they deserve, as well as to choose caregivers and models of care that promote natural and undisturbed birth (Buckley 2005). We can meet mothers where they are, and help them to make truly informed decisions by illustrating how breastfeeding initiation may be affected by epidural use.

As Leaders, we can encourage mothers to be informed about their birthing options and build up mothers' confidence that they are capable of natural birth. Be mindful of those mothers who have had epidurals or plan on having them -- reassure them that La Leche League Leaders are there to help them and support them should breastfeeding problems arise.